Provider Demographics
NPI:1063957587
Name:JOHNSON, TRACY ANN
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:ANN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TRACY
Other - Middle Name:ANN
Other - Last Name:MCDONALD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1626 6TH AVE N
Mailing Address - Street 2:
Mailing Address - City:GREAT FALLS
Mailing Address - State:MT
Mailing Address - Zip Code:59401-1720
Mailing Address - Country:US
Mailing Address - Phone:406-899-0143
Mailing Address - Fax:
Practice Address - Street 1:1626 6TH AVE N
Practice Address - Street 2:
Practice Address - City:GREAT FALLS
Practice Address - State:MT
Practice Address - Zip Code:59401-1720
Practice Address - Country:US
Practice Address - Phone:406-899-0143
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-20
Last Update Date:2016-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No172V00000XOther Service ProvidersCommunity Health Worker